How to treat kyphosis (kyphotic deformity)?

Treatment of Kyphotic Deformity

Surgical intervention is recommended for patients with kyphotic deformity causing significant disability, pain, segmental instability, or cosmetic concerns affecting quality of life, particularly when conservative management has failed. 1

Assessment and Classification

• Evaluate the etiology of kyphosis:

  • Postural kyphosis (no structural deformity)
  • Scheuermann's kyphosis (vertebral wedging and disk space narrowing)
  • Congenital kyphosis
  • Post-traumatic kyphosis
  • Degenerative kyphosis

• Assess severity using:

  • Radiographic measurement of Cobb angle
  • Functional impairment evaluation
  • Pain assessment
  • Neurological examination

Treatment Algorithm

Conservative Management (First-Line)

For mild to moderate kyphosis without significant symptoms:

1. Physical therapy and exercise:

   • Strengthening of abdominal and back extensor muscles
   • Stretching exercises for lower extremity contractures
   • Postural training for stance and sitting 2

2. Bracing:

   • Indicated for skeletally immature patients with Scheuermann's kyphosis
   • Can result in permanent correction of vertebral deformity, unlike in scoliosis 2
   • Milwaukee brace or thoracolumbar orthosis for 16-23 hours daily

3. Pain management:

   • NSAIDs for symptomatic relief
   • Activity modification

Surgical Management

Surgery is indicated when:

1. Progressive deformity despite conservative treatment
2. Kyphosis >70-75 degrees
3. Significant pain unresponsive to conservative measures
4. Neurological compromise
5. Significant functional or cosmetic concerns affecting quality of life 1

Surgical Techniques:

1. Posterior Approach:

   • Posterior instrumentation and fusion
   • Suitable for moderate deformities
   • Lower complication rate compared to combined approaches

2. Osteotomy Techniques:

   • Smith-Petersen osteotomy: For flexible deformities
   • Pedicle subtraction osteotomy: For rigid deformities
   • Vertebral column resection: For severe, rigid deformities
   • Closing-opening wedge osteotomy: Can achieve significant correction (average 49°) with a single posterior approach 3

3. Combined Anterior-Posterior Approach:

   • Indicated for severe rigid deformities
   • Two-stage procedure with anterior release followed by posterior instrumentation
   • Higher complication rate but better correction

4. Expandable Cage Technique:

   • Distractible titanium cage via posterior approach
   • Suitable for patients who cannot tolerate anterior approaches
   • Can achieve 53% correction of kyphosis 4

Special Considerations

Age-Related Considerations:

• Children and Adolescents:

  • Focus on preventing progression during growth
  • Bracing is more effective in skeletally immature patients 2
  • Early surgical intervention may be necessary for congenital kyphosis to prevent progression (5° per year) 5

• Adults:

  • Focus on pain relief and functional improvement
  • Higher risk of complications with surgery

Complication Prevention:

• Neurological complications: Use neuromonitoring during surgery
• Instrumentation failure: Ensure proper pedicle screw placement and adequate fusion length
• Adjacent segment degeneration: Restore proper sagittal balance 1

Post-Treatment Follow-up

• Regular clinical and radiographic assessment at 12 months post-surgery
• Earlier assessment if deformity worsens or clinical concerns arise
• Functional assessment using standardized tools
• Long-term monitoring until skeletal maturity in pediatric patients

Cautions and Pitfalls

• Elective spinal osteotomy carries significant risks (4% perioperative mortality, 5% permanent neurologic sequelae) and should be performed only at specialized centers by experienced surgeons 6
• Bracing has limited effect on fixed kyphotic deformities 5
• Surgical correction of thoracic kyphotic deformity is associated with significant surgical and neurological morbidity 4
• Recurrence of deformity is common, especially in young children and patients with poor metabolic control 6

The treatment approach should be guided by the severity of deformity, patient symptoms, skeletal maturity, and underlying etiology, with surgical intervention reserved for cases where conservative management has failed or significant disability exists.